A beautiful island country of only 25,300 square miles, Sri Lanka has a bloody history, full of war and ethnic conflict. Source: Creative Commons.

Although many refer to Sri Lanka as a success story in achieving high health outcomes despite its low income, a crucial side of its past often remains unaddressed. An island country of only 25,300 square miles, Sri Lanka has a bloody history, full of war and ethnic conflict.1 After a brutal 50-year civil war ended in 2009, the people of Sri Lanka took their first steps on a long path toward recovery. Many suffered conspicuous physical injuries, but the most pressing damage was invisible to the naked eye. As a country where mental health issues still carry harmful cultural stigma, Sri Lanka struggles to provide adequate treatment for the mental illnesses caused by the conflict.

The Sri Lankan Civil War was, at its core, a struggle for territory and power between the ethnic minority Tamils and the majority Sinhalese. Early tensions caused by ethnic differences were exacerbated by institutionalized discrimination against the Tamil population.2 This chauvinism revealed itself everywhere, from “affirmative action” laws put in place by the mainly Sinhalese government to limit the number of Tamil university students, to stereotypes made permanent in classroom textbooks.2,3 The first acts of organized violence began in 1956, and culminated in a series of race riots in 1983, which became known as Black July.2

Once the violence began, many different players entered into the conflict. This list included the Sri Lankan army, the Sinhala militant group, Janatha Vimukthi Perumana (JVP), the Indian Peacekeeping Force, which entered Sri Lanka in an effort to help the government resolve the conflict, and the Liberation Tigers of Tamil Eelam (LTTE), a group dedicated to fighting for an independent Tamil state in the Northeast.4 All parties involved used terror as a weapon. Common “counter-insurgency techniques” used by the Sri Lankan army included torture and mass displacement.4 The induction of child soldiers also became increasingly common, especially within the LTTE, because it proved easier to condition children into fearless obedience than adults.5 One Sri Lankan recalls how, in 1984, “the army had set up random checkpoints throughout the Tamil areas. When you saw an army truck, you didn’t want to run because they might think you were guilty. But sometimes, especially right after an [LTTE] attack, they would shoot civilians and Tigers alike, at random.”6 By the peak of the conflict in 1995, every group involved was under scrutiny by Amnesty International for multiple human rights violations, including torture, mass disappearances, and extrajudicial executions.7

The Sri Lankan Army was only one of the players involved in the conflict, but, at one point, every party involved was under scrutiny by Amnesty International for multiple human rights violations, including torture, mass disappearances, and extrajudicial executions. Source: Creative Commons.

The war ended in 2009, when the Sri Lankan Army brutally defeated the separatist forces, and any remaining members were exiled. Even after the fighting had ceased, a general sense of uneasiness remained as a result of the sheer amount of destruction. The damage was especially severe in the mainly Tamil northeast region of the country, where the LTTE had been based before being massacred by the army. The terror wreaked by the conflict lasted through multiple generations, and the trauma it created became normalized. Dave Sacco, a volunteer with the United Nations High Commission for Refugees (UNHCR) based in Sri Lanka from 1995-1996, explains “The war lasted a long time, but the fighting was only acute for short, nasty periods… People adapted and life moved on, mostly because it had to. There were times when, aside from all of the people with guns, life seemed challenging but still ‘normal.’”8

The effects of this continual state of war seeped into all aspects of society. Both Tamil and Sinhalese citizens learned passivity and submissiveness in order to survive. Those who dared to question authority were weeded out with various intimidation techniques. This forced obedience and loss of leadership resulted in “the vital capacity to rebuild and recover… being suppressed.”4 The Tamil people learned to mistrust the Sri Lankan government, and remain suspicious today. After the war, internally displaced peoples (IDPs) became dependent on monetary handouts for income, and lost the self-motivation to succeed.2 Social norms shifted, and both substance abuse and domestic violence became much more prevalent. One study reported that 95.6% of children in the Northeast, the most war-affected region, had experienced at least one incidence of family violence after the war and in 64.2% of the families, the violence was recurrent. Over 18% of children had suffered at least one injury as a result of family violence.9 The same study found that both substance abuse and exposure to the war were strong predictors of violence in the home. The Sri Lankan Civil War may have broken the psyche of its people, but the cycle of violence and societal changes the war effected continued to break the minds and spirit of the people, even after the fighting had ended.

The Sri Lankan people began to experience a host of mental disorders, but neither the health system nor society was prepared to address them. Post-traumatic stress disorder (PTSD), various anxiety disorders, major depressive disorder, and somatization disorder — a disorder marked by numerous medically unexplainable physical symptoms due to psychological distress — became common among those affected by the war.2 One study showed a strong relationship between exposure to war and the number of PTSD symptoms reported, drawing a direct connection between the war and the mental disorders affecting the population.9 The number of suicides skyrocketed, reaching 17.1 per 100,000 citizens in 2012 and making Sri Lanka the country with the 22nd highest suicide rate in the world.10

The government, however, neglected the mental health issues plaguing its citizens, and focused most of its rehabilitation efforts on the treatment of physical illnesses. This lack of awareness was likely caused by the cultural stigma against mental disorders that was due, in part, to Buddhist and Hindu religious beliefs in illness as punishment for poor karma, familial concern for the negative marital effects of mental disorders, and an irrational fear of unprovoked violence caused by mental illness.11 Dave Sacco, the UNHCR volunteer, described how this stigma presented itself during the peak of the conflict: “People were very stoic, they didn’t tend to talk much about their troubles. When I finally heard [about their troubles], they were pretty matter-of-fact; [there was] usually not much anger or resentment expressed. [There was much more] stoicism and fatalism. And suicide.”8 The stigmatization of mental health issues resulted in social exclusion of those with mental disorders, widespread lack of awareness, and lack of belief in the efficacy of prescription medicine and therapy.11 These factors led to low participation rates in existing mental health programs.11 Stigma continues to present a significant obstacle to improved mental health within Sri Lanka today.

Among those affected by the war, children, especially those who experienced the conflict throughout their formative years, are most vulnerable to mental disorders. Although most children were affected in some way by the war, the conflict was largely concentrated in the northeast region of the country and therefore disproportionately affected Tamil children. In one survey conducted in a northeast province, 92% of the children reported experiencing severely traumatizing events and 79% had had some form of combat experience.12 Immediate impacts on children due to these kinds of traumatic events have been found to include numbness, hyper-vigilance, shock, unresponsiveness, muteness, and/or frantic behavior.2 Longer term effects included increased aggression, anxiety, depression, suicidal behavior, and/or attention deficit disorders.13 Children are also particularly susceptible to permanent personality scarring during periods of emotional, cognitive, and endocrinological development. Because the Sri Lankan conflict has extended throughout multiple generations, it has severely impacted children’s lives and health.12

The most common disorder caused by extensive trauma, however, is PTSD. The impact of PTSD is very evident in northeast Sri Lanka, where 25% of children meet the criteria for a diagnosis.12 In situations of extensive and brutal violence, PTSD can often become malignant, resulting in an addiction to violence.2 Because children are more susceptible to influence from their environs, it can be hypothesized that the children directly involved with the conflict also proved more susceptible to malignant PTSD than adults. This correlation has yet to be investigated, but data shows that PTSD in children is often accompanied by many different complications. Almost 12% of the children who suffered from PTSD in the northeast region suffered concurrent anxiety disorders, and were more likely to experience depressive and/or somatic symptoms.12 This high prevalence of concurrent disorders indicates the immense need for more comprehensive treatment.

In several studies, UNICEF has emphasized the need for thorough, post-conflict psychosocial and physical healthcare for children in order to prevent them from drifting into a life of “further violence, crime, and hopelessness.”5 Sri Lanka’s initial rehabilitation efforts during the war, however, did not meet this need, and actually exacerbated the psychosocial issues of those targeted by mental health programs. The government viewed child soldiers who were captured or surrendered during the war as criminals, and therefore, designated the responsibility of their rehabilitation to the Sri Lankan army, rather than trained mental health workers.2 This criminal treatment is ineffective at best, and, at worst, aggravates pre-existing conditions and creates new ones. Even if children could return home after being displaced, the deteriorated social climate due to the war continued to affect their psyches. The increased prevalence of violence at home meant children were continually exposed to trauma, increasing their risk of experiencing PTSD as adults.14 In addition, exposure to domestic violence is associated with long-lasting cognitive impairment, and low intellectual and academic outcomes.13 These effects, along with the disruption of education by the conflict, decrease a child’s ability to maintain financial stability after the war and increase the likelihood of future mental stress.

Despite initial failures, the Sri Lankan government has now realized the need for action, and currently partners with several non-governmental organizations (NGOs) to implement various programs throughout the country. Although a largely unmet need for trained mental health professionals still plagues Sri Lanka, such that only one psychiatrist is available per every 500,000 citizens, community workers are often employed to increase the accessibility of services.11 In at least one city in the northeast, local medical students, nurses, and primary health workers undergo training in basic mental health, and general mental health awareness programs have been implemented at all levels of schooling.2 In some communities, locals have created programs with the help of NGOs to train counselors in trauma therapy, who are then employed to generate support systems and provide catharsis for both children and adults.2

Buddhism is the major religion within Sri Lanka. Religion provided a source of resilience for many during the war, but may have also contributed to the still-present cultural stigma against mental disorders. Source: Creative Commons.

Western medical techniques may not, however, represent the most effective method of addressing Sri Lanka’s mental health burden. Stigma and lack of awareness cause few patients to seek help, and those that do so will often go to traditional healers, rather than Western-trained health workers. Some traditional relaxation techniques, such as yoga and meditation, have been found to be effective, but the preference for traditional healers causes a delay in Western psychosocial treatment that can decrease the efficacy of medical treatment, once begun.11,15 If traditional healers are trained to identify major disorders and refer their patients to medical workers, they can become a major asset for mental health. Once Sri Lanka has increased its capacity for trauma therapy, this kind of partnership with traditional leaders will be needed to reach as many patients as possible.

Before a partnership can be established, the Sri Lankan government must openly address the mental health burden and take action to decrease the still-present cultural stigma against mental illness. The need for improved education remains high. Specific programs targeting medical workers and those in positions of authority, such as teachers and religious leaders, are also needed to effectively decrease stigma. Currently, the burden of mental healthcare falls mainly on the shoulders of community health workers; however, due to the stigma against their work, they themselves often experience burnout and psychological stress.11 The lack of mental health knowledge among trained medical workers further exacerbates this stress by extending this stigma into the medical field.

The government has acknowledged the need for action to decrease this stigma, as well as the existence of high suicide rates and increased prevalence of psychological symptoms, but still claims that only 2% of its population suffers from “serious” mental illnesses.16 Only after admitting the full extent of the mental health issues among its citizens can the government take action to raise awareness among other authority figures, and effectively address the mental health burden. The involvement of these authorities, including community leaders, teachers, and religious figures, is necessary to ensure the distribution of care to all groups. Teachers have already proven to be a large asset in addressing the mental health burden of children. School-based cognitive behavioral therapy has previously been effective in trauma treatment in Armenia, and Sri Lankan teachers have proven reliable when completing diagnostic assessments of their students’ mental health, two factors that indicate the potential success of similar programs that may be launched across Sri Lanka in the future.17,12

Before these additional countrywide programs can be implemented, the organization of the existing programs must be improved. The current lack of communication among mental health workers, for example, impedes the efficacy of their work.11 As of 2012, training of a few workers within the existing primary healthcare infrastructure had begun, but this training must be made universal in order to become truly effective.11 Additionally, the government must first rebuild the pre-war healthcare system, which collapsed during the fighting, before implementing any further programs.

While preparing for post-war recovery, Sri Lanka must also adjust its health system to meet the new demands of a country undergoing an epidemiological transition: the shift from a mostly communicable burden of disease to a much larger, non-communicable disease burden.18 Mental disorders account for 11.5% of this new burden of disease.19 Therefore, Sri Lanka desperately needs localized facilities dedicated to mental healthcare. Current evidence has shown that patients often fail to reintegrate with their families and communities after psychiatric hospitalization, due to long-term separation in distant mental health hospitals.17 The government currently plans to address this problem by establishing an acute inpatient ward within each of the country’s 25 districts, but steps must be taken to ensure that all populations, especially rural ones, can access these facilities.16 The plans outlined above can help address the massive mental health burden that Sri Lanka currently faces, but only if they are made with special consideration to the contexts of family, community, and society. Programs must be comprehensive, treating symptoms while maintaining focus on the core issues.

Seven years have passed since the end of the Sri Lankan Civil War, and the government has finally begun to work towards recovery and rehabilitation. But many steps are still needed to fully heal the people. Due to a uniquely long and brutal war, a series of complex issues, including collapsed health infrastructure, an extensive mental health burden among children, and a shift in the burden of disease, must be addressed. Awareness of the full extent and complexity of these mental health issues must be raised among both the Sri Lankan government and the general population in order to successfully implement effective treatment programs. With the dedication of time and resources, however, these programs may allow the people of Sri Lanka to prosper for the first time in over fifty years.

Ohvia Muraleetharan is a junior in Pierson College. She is a Biomedical Engineering major and can be contacted at ohvia.muraleetharan@yale.edu.